CURRICULUM VITAE

Nama : Dr.dr.Banundari Rachmawati SpPK(K)

Tempat/Tgl lahir : Pemalang, 1 6 Juni 1960

Alamat : Puri Ayodya D6, Ngesrep timur VI Semarang

Status : Menikah , anak 2
Pekerjaan : -Staf Pengajar FK UNDIP, Program PPDS I PK ,
PPDS2 PK , S2 Gizi Klinik , S3 FK UNDIP
-Kepala Unit Transfusi Darah PMI Prov Jateng
Alamat kantor : Bagian PK FK UNDIP
- Jl dr Soetomo 14 Zona Pendidikan Semarang
- Jl Prof Soedarto Gedung gd C Tembalang
Semarang
Riwayat Pendidikan:
- Lulus FK UNDIP 1987
- Lulus PPDS I PK FK UNDIP th 1997
- Konsultan metab endokrinologi (Kolekium- UNAIR) 2007
- Lulus S3 Program Doktor Ilmu Kedokteran UNDIP 2012
 RATIONALE
TRANSFUSION
AND ITS PROBLEMS

BANUNDARI RACHMAWATI
BAGIAN PATOLOGI KLINIK FK UNDIP
RSUP DR KARIADI SEMARANG
Rational Use of Blood
RATIONAL
(Rationale behind Rational use of
blood)

Economy - Scarcity of resource

1 in 4 get blood component

Safety - Inherent risks involved

in transfusion therapy
1 in 2 million gets HIV

Scientifically appropriate
Haematinic in nutritional anemia
Guidelines For Promoting Component Therapy

Definite indication - A blood transfusion should

never be ordered unless it is worth the risk

Single unit transfusion – has no significant

therapeutic benefit

Use of fresh blood - should be avoided because

of increased risk of infections
Give only what is needed
Red cells O2 carrying
capacity (Anemia)

Platelets Thrombocytopenia

FFP Multiple clotting

factor deficiency

CRYO Hemophilia A
Four reasons why excessive transfusion
is a problem

Reason 1:

Each transfusion increases the risk of

nosocomial infection increases other
morbidities
Four reasons why excessive transfusion
is a problem

Reason 2:

the higher the number of transfused

RBC, the higher was the number of
clinical complications.
Four reasons why excessive transfusion
is a problem

Reason 3:

Transfusion associated circulatory

overload (TACO) is the high risk
adverse effects of red cell transfusion
Four reasons why excessive transfusion
is a problem

Reason 4:

. Each unit of red cells transfused is

associated with increased risk for
adverse outcome.
 Whole blood or red cell transfusion

The transfusion of red cell Blood products can transmit

products carries a risk of infectious agents—
incompatible transfusion and including HIV, hepatitis B,
serious haemolytic hepatitis C, syphilis, malaria
transfusion reactions. etc—to the recipient.

Any blood product can

become bacterially
contaminated and very
dangerous if it is
manufactured or stored
incorrectly.
 Permenkes 91
BAB VI
PEMBERIAN TRANSFUSI DARAH KEPADA PASIEN

Setiap transfusi darah harus

dilakukan atas dasar
indikasi, jenis ,volume
darah atau komponen
darah, serta waktu yang
tepat.

PRINSIP
 Permintaan yang berlebihan dapat
menyebabkan:

• Menurunnya stok darah sehingga

pasien yang benar-benar
membutuhkan tidak mendapatkan
stok darah.

• Meningkatnya biaya pengganti

pelayanan darah yang harus
biaya diganti oleh pasien atau penjamin.
sebelum meminta darah, dokter harus menyiapkan
dan mempertimbangkan beberapa hal
A.Penggunaan PERBAIKAN
darah sesuai YANG
INGIN
indikasi klinis DICAPAI

CATAT DI
T/ LAIN
CM

PILIHAN INDIKASI
LAIN KLINIS
sebelum meminta darah, dokter harus menyiapkan
dan mempertimbangkan beberapa hal
B.Penggunaan
darah yang
rasional.

MEMINIMAL JENIS DAN

KAN VOLUME
KEBUTUHAN SEDIAAN
DARAH DARAH
sebelum meminta darah, dokter harus menyiapkan
dan mempertimbangkan beberapa hal
C.Reaksi transfusi
PENULARAN
IMLTD

REAKSI KONTAMINA
HEMOLISIS SI BAKTERI

ALERGI
TRALI
TACO
 Pengecekan Identitas Darah Donor dan
Pasien

Identifikasi pasien (2 orang)

identifikasi kantong darah
di sisi pasien
— jenis dan volume
sediaan
— Nama lengkap.
— Kecocokan golongan
darah — Tanggal lahir.
— Nomor kantong — No rekam medis.
— Expired date — Jenis kelamin.
— Hasil uji pratransfusi. — Golongan darah.
— Keadaan kantong darah

Bila terjadi perbedaan : darah tidak dapat ditransfusikan.

Insiden ini dilaporkan sebagai Kejadian Nyaris Cedera
 Darah dan
komponen darah
serta indikasi
pemberiannya
 Platelets 2nd centrifugation Platelets
rich
concentrate
Whole
Whole plasma
blood
blood
1stcentrifugation
FFP for
clinical use
Red
Fresh plasma FFP for
Cell fractionation
concentrate

Optimal additive
Cryoprecipitate
solution

Red cells in
OAS What can we give?
 20

What are expected

What can we give? outcomes?
— Whole blood
— Packed RBC (PRBC)
— Platelets
— Fresh Frozen Plasma
(FFP)
— Granulocytes
— Cryoprecipitate
— Factor VIII
— Albumin
 Whole Blood
— Clinical indications for use of WB are extremely limited.
— Used for massive transfusion to correct acute
hypovolemia such as in trauma and shock, exchange
transfusion.
— RARELY used today, platelets non-functional, labile
coagulation factors gone.
— Must be ABO identical.
 Whole blood vs Packed red cells

Parameter Whole blood Packed red cells

Volume 350 – 450 ml 200 – 240 ml
Increment in Hb 1 -1.5 gm/dl 1 -1.5 gm/dl
Red cell mass /ml Same as PRBC Same as WB
Viable platelets No No
Labile factors No No
Plasma citrate ++++ +
Allergic reactions ++++ +
FNHTR ++++ +
Risk of TTI ++++ +
Waste of components Yes No
 Why whole blood not rational
• Maximize blood resource
Whole blood one patient
Component therapy four patients
packed red cells thalassemia
plasma liver disease / burns
platelets thrombocytopenia
cryoprecipitate hemophilia
Specific storage requirements of components
Whole blood + 40 C
Components
platelets + 20 – 24 oC
cryoprecipitate & FFP - 30oC
red cells + 2 – 80 C
 Why whole blood not rational

• Better patient management

• concentrated dose of required component
• avoid circulatory overload
• minimize reactions
eg. Requirement of platelets to raise count from 20 to 50,000/ul
fresh whole blood 5 units 1750 ml
random platelets 5 units 250 ml
apheresis platelets 1 unit 200 ml

• Decreased cost of management

except for the cost of bag, other expenses remain same
 “Fresh blood” – a misconception
4What is “fresh blood”?
§ unit kept at 4oC for 4 hours is no longer “fresh”
§ storage lesions in different constituents due
to storage temp
4Increased risk of disease transmission
§ intracellularpathogens (CMV, HTLV)
survive in leukocyte in fresh blood
§ syphilis transmission
Treponema can not survive > 96 hours in stored blood
§ malaria transmission
malarial parasite can not survive > 72 hrs in stored blood
“Fresh blood” – a misconception
4Immunological complication due to WBCs
in fresh blood

§TA-GvHD – 90% fatality

§TA-immunomodulation
§ alloimmunization
4Logistics
§ no time for component preparation
§ less time for infection screening
§ increased chances of error
 Darah lengkap/ whole blood

INDIKASI
*perdarahan akut /massif Kontra indikasi
dengan hipovolemia.
*Transfusi tukar — Risiko overload
*Butuh transfusi PRC, tapi — Anemia kronik
di stock tidak tersedia.
— Gagal jantung awal

DOSIS
Pada anak: transfusi
massif 15-20 mL/kgBB,
bergantung ku umum
saat itu
 Darah lengkap/ whole blood

MANFAAT
Pasien dewasa: 450 mL
( Hb 1 g/dL, Ht 3-4% ) — CARA PEMBERIAN
Pasien anak, WB 8 mL/kg — Blood set baru , filter 170 –200 µ.
Hb 1 g/dL — transfusi maks 30 menit setelah darah
keluar .
— Obat tidak boleh
— Selesai maksimal 4 jam .
— Ganti blood set setiap 12 jam / 4
RISIKO TRANSFUSI kantong darah( mana yang lebih cepat).
Tidak disterilisasi,
kemungkinan masih
menularkan IMLTD, malaria,
bakteri dan penyakit lainnya.
 Packed Red Cells

• RBC’s
Contents • 20% Plasm

• Replace O2 carrying capacity with

less volume
Indications • Severe anemia, slow blood loss, CHF
Guidelines for blood component therapy
Haemoglobin (Hb) Indications NB: Hb should not be the sole deciding factor
trigger for for transfusion.
transfusion
•If there are signs or symptoms of impaired oxygen transport

•Lower thresholds may be acceptable in patients without

< 7 g/dL symptoms and/or where specific therapy is available e.g. sickle
cell disease or iron deficiency anemia

•Preoperative and for surgery associated with major blood

< 7 – 8 g/dL
loss.
•In a patient on chronic transfusion regimen or during marrow
suppressive therapy.
< 9 g/dL
•May be appropriate to control anaemia-related symptoms.

< 10 g/dL •Not likely to be appropriate unless there are specific

indications.
• Acute blood loss >30-40% of total blood volume.
 Packed Red Cells/ PRC
INDIKASI
*Hb , 7 g/dl. Asimtomatik /ada T/ lain,Hb
dapat lebih rendah
*Hb 7-10 g/dl dengan hipoksia
*Hb ≥ 10 misal PPOK
*neonatus dengan hipoksia : Hb ≤11 g/dL;
tanpa hipoksi 7 g/dL
*Neo + Peny Jantung/Paru untuk oksigenasi
Hb ≤13 g/dL.

Kontra indikasi
— Risiko overload
— Anemia kronik
— Gagal jantung awal
 Packed Red Cells/ PRC

• Pada anak:
• Hb > 6 g/dL, 15 mL/kgBB/Hari
• Hb < 5 g/dL , 1 jam pertama 5 mL/kgBB, sisa darah
Dosis dihabiskan dalam 3 jam berikutnya,
• Pada neonatus 20 mL/kgBB, kantong Pediatrik 50 mL.

• Pasien dewasa : sama dengan WB

Manfaatt • pasien anak, PRC 8-10 mL/kg Hb 2 g/dL / Ht 6%.

• Sama dengan WB
• Spy lancar sebelumnya dapat diberikan Na Cl 0,9 % 50-
Cara 100 ml
 PRC Leukocyte Reduced/depleted
Leukocytes can induce
adverse affects during Reactions to cytokines
transfusion: febrile, non- produced by leukocytes in bag.
hemolytic reactions.

Immunization of recipient to transfused

“CMV” safe blood (CMV lives HLA or granulocyte Ag, micro
in WBCs). aggregates and fragmentation of
granulocytes.

Indicated only for patients who had 2 or >

febrile transfusion reactions
Leukocyte-depleted or WBC-depleted RBCs

• Provides 90% of red blood cells and

Sedimentation: 10% of original no of platelet and
leukocyte.

• Provides a good recovery of

Washing: erythrocyte with low no of WBC and
platelet.

Frozen
• when maximally leukocyte poor red
deglycerolized blood cells needed.
red cells
 Washed red cells

free of almost all traces

convenient but of plasma, most WBCs,
expensive.
and platelets.

In IgA-immunized
given to patients who patients, blood collected
have severe reactions to
from IgA-deficient
plasma (eg, severe donors may be
allergies, PNH, or IgA
preferable for
immunization). transfusion.
 washed Erythrocyte/ WE)

INDIKASI = PRC
* pasien alergi atau demam pada KONTRA INDIKASI
transfusi sebelumnya DOSIS = PRC
*Pasien dengan hiperkalemi

CARA PEMBERIAN= PRC

MANFAAT=PRC
Dapat diberikan bersama NaCl
fisio 50-100cc USIA <prc
Trombosit Konsentrat/Concentrate
Thrombocyte/TC

Contents
• Platelets
• WBC’s
• Plasma
 Trombosit Konsentrat/Concentrate
Thrombocyte/TC

Indications
Platelet concentrates are used to prevent
bleeding in:
asymptomatic Bleeding patients
severe < severe
thrombocytopenia thrombocytopenia
( TA < 10,000/µL) (TA < 50,000/µL)

Patients receiving Bleeding patients

Before invasive massive transfusion with platelet
that causes dysfunction due to
surgery. dilutional antiplatelet drugs but
thrombocytopenia with N platelet count
INDIKASI KONTRA INDIKASI
— perdarahan , jumlah — ITP kecuali dengan
trombosit <50.000/uL perdarahan mukosa aktif
— Perdarahan mikrovaskular trombosit < 20.000/uL
difus : <100.000/uL — TTP
— perdarahan massif. — DIC yang tidak diobati
— DHF DAN DIC sesuai SOP — Trombositopenia karena
— <50.000/uL : pre operasi septikemia, hipersplenisme
/ prosedur invasif / pasca
transfusi masif.
— Kelainan fungsi trombosit
dengan perdarahan.
— Pencegahan perdarahan
akibat trombositopenia,
DOSIS
*Pooled unit: 4-6 donor — CARA PEMBERIAN
*1 kantong TC/10 kg — -TC harus segera ditransfusikan
BB, biasanya 5-7 kantong
dewasa. — Exp date 4 jam pasca pooling
*Anak dan neonatus: — ( bakteri.)
10-20 mL/kgBB/hari
— -Tidak boleh disimpan suhu 2 –
6⁰ C
— -trombosit set.
MANFAAT — -Lama transfusi 20 menit,
-1 kantong , pasien BB 70 apheresis dan pooling < 2 jam
kg naik 5000/µL
Peningkatan trombosit
< pada Splenomegali
DIC
RISIKO=P
Septikemia RC
 Fresh Frozen Plasma (FFP)

INDIKASI
*Defisiensi F IX
*Pasca T/ heparin
*perdarahan ( F Koagulasi
abnormal ) akibat :
Transfusi massif, operasi KONTRA INDIKASI
pintas jantung paru atau
penyakit hati. — tidak boleh
*Trombosit turun setelah digunakan sebagai
transfusi masif pengganti volume
darah/sumber
protein
 Fresh Frozen Plasma (FFP)

DOSIS
Dewasa : dosis inisial
15 mL/kg BB CARA PEMBERIAN
-Tidak perlu CM.
(4-6 kantong). -Plasma thawer (suhu 30 - 37⁰C).
Anak dan neonatus: -Cir simpan T 2–6⁰C(24 jam).
10-20 mL/kgBB/hari -Ditransfusikan dalam waktu 20mnt
(maks 6 jam setelah cair).

RISIKO TRANSFUSI
Reaksi alergi akut(transfusi cepat)
Reaksi anafilaktik .
Kontaminasi bakteri
Cryoprecipitate/Faktor Anti Hemofilik
(Anti Hemophilic Factor/AHF)

• defisiensi fibrinogen
• Hemofilia A dan penyakit Von
INDIKASI Willebrand dengan perdarahan,tidak
responsif dengan desmopresin asetat /
akan operasi.
• Defisiensi faktor XIII.

KONTRA • Tidak untuk pasien defisiensi faktor

INDIKASI pembekuan lain.

• Satu unit ( satu donor)

DOSIS • Pooled unit: satu kantong AHF ≥ 6 donor
Cryoprecipitate/Faktor Anti Hemofilik
(Anti Hemophilic Factor/AHF)

• Tidak perlu CM.

• Setelah cair segera
CARA ditransfusikan maks 6 jam .
PEMBERIAN • Menggunakan blood set.

• Fibrinogen naik 5-10 mg/dL/

MANFAAT kantong

RISIKO • Sama dengan plasma

 Perhatian khusus pada pemberian
transfusi

• Darah tidak perlu dihangatkan, kecuali : transfusi

Tidak cepat, masif, tukar atau ada cold agglutinin.
dihangatkan

• Bila pasien mendapatkan transfusi TC dan sediaan

lain, transfusi TC harus didahulukan dengan
Trombosit
dulu trombosit transfusion set /blood set yang baru

• Transfusi melalui vena sentral hanya boleh

Vena dilakukan oleh perawat terlatih
sentral
 • Pasien harus diawasi dengan
baik.
• Mulai transfusi
• 15 menit pasca transfusi
• selesai transfusi
MONITORING
TRANSFUSI • Rawat inap : 4 jam pasca
transfusi kantong terakhir
• Rawat jalan 1 jam pasca
transfusI
• Setelah selesai periksa tanda
vital
 • Persetujuan transfusi
• Alasan dan target transfusi.
• Nama dan tanda tangan dokter
DPJP.
MONITORIN
G • Hasil verifikasi pre
transfusi : identitas pasien dan
TRANSFUSI kantong darah , nama dan td
tangan dua petugas yang mem
CATAT DI CM verifikasi
• Transfusi yang dilakukan:
jenis volume , nomor kantong,
golda, waktu mulai , nama
petugas yang memberikan
 • Pengawasan ; KU, suhu
tubuh, nadi, tensi, RR
MONITORIN • Pasca transfusi , reaksi
G TRANSFUSI transfusi.
• Cek kadar Hb 1 jam (paling
baik 24 jam pasca transfusi)
CATAT DI CM
• Cek kadar trombosit 10-60
menit dan 18-24 jam pasca
transfusi.
 • Kegagalan mencapai jumlah
trombosit yang diharapkan :
status refraktori.,
• imunologis berhubungan dengan
MONITORIN Ab terhadap Ag HLA dan Ag
spesifik trombosit .
G TRANSFUSI • Refraktori trombosit klinis
berhubungan dengan perdarahan,
pemberian obat amfoterisin,
CATAT DI CM splenomegali, DIC, demam, sepsis /
transplantasi sel progenitor
hematopoetik.
• Pasca transfusi FFP, 30-60 menit
kemudian periksa aPTT dan PT
PENUTUP

TRANSFUSI HARUS
RASIONAL DENGAN
ALASAN MEDIS,
KEAMANAN, LOGISTIK,
BEAYA